MARK HARRISON, M.B., B.S. (old.), D.0. (Melb.), F.R.A.C.S. Princess Alexandra Hospital, Brisbane.

SUMMARY A SIMPLIFIED dacrocystorhinostomy using

Hegar’s cervical dilators and taking less than half an hour to perform, has a low failure rate even in the hands of the infrequent operator. It is the operation of choice for recurrent acute dacrocystitis, but is equally successful in chronic dacrocystitis.

INTRODUCTION Simplified dacrocystorhinostomies come and

go. They come because the standard operation is both difficult and time consuming. They go because the results are poor. There is a great need for a simplified operation because it is easier to allow patients to suffer the misery of a watering sticky eye for years rather than face the daunting prospect of the (lifficult clnssical operation with suturing of anterior and posterior flaps. However, a simplified operation can be justified only if the results are satisfactory. The purpose of this paper is to describe my variant of the simple Stearn’s dacrocystorhinostomy (Kinosinn, 1963) using Hegar’s cervical dilators and t o report the long term results.

OPERATION This is performed under general anacsthesia.

The surgeon should check that the anesthetist has inserted a pharyngeal pack. The nose is packed lightly with ribbon gauze. This can be done blindly without elaborate headlights or mirrors and is not an essential part of the operation.

The incision is made directly over the anterior wall of the sac and in the case of a mucocele, the skin and sac can be opened with a single stroke of the knife.

Once the sac is opened, a small Hegar’s cervical dilator is forced through the inferior

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part of the medial wall of the sac into the nose. Increasing sizes of dilators are forced through the hole up to a No. 9 dilator. The hole in the bone is further enlarged with a Kerrison sphenoidal punch until it is approxi- mately 15 mm. diameter. A vaseline gauze pack is put down through the hole and brought out through the nostril.

The anterior wall of the sac is closed with interrupted 5-0 plain catgut sutures, one of which includes a few fibres of the gauze pack. The skin is sutured with interrupted silk. The end of the gauze pack protruding from the nostril is sutured to the nostril and cut off flush. The pack is removed on the third day, the sac irrigated and the patient sent home.

PATIENTS AND FOLLOW-UP The records of Princess Alexandra Hospital

were searched and a total number of sixty-two primary operations were located. These were performed on 58 people (i.e. four bilatcral operations) by thirteen surgeons.

Of these operations, follow-up for a t least six months with an average of 3 . 3 years could be obtained in forty-eight cases. Almost all failures in follow-up are country patients. The distances in Queensland are sufficiently large to make review of these impracticable.

The city patients were circularized if the outpatient notes were inadequate or if they had not returned for a check at least six months post-operatively.

All the patients had the relevant teardnct syringed and patency or lack of it verified. The criterion of success is lack of symptoms and a patent tearduct a t least six months post-operatively .

RESULTS There were 37 primary successes (approxi-

mately 77 O/”) . Three failures were subjected to a second operation which was successful in every case.

Two patients with recurrent acute dac- rocystitis were completely relieved of

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symptoms but examination showed blocked common canaliculi. There were six complete failures i.e. they not only had blocked nasolacrimal ducts but were not relieved of symptoms. Thus the final overall failure rate was eight out of forty-eight i.e. 1 7 % . This decreases to a 13% failure rate if the two patients with relief of symptoms but blocked common canaliculi are included as successes (vide infra).

COMMENT There are a number of differences from the

classical operation. The incision is lower and it is never necessary to cut the medial palpebral ligament because the sac is left in situ. At the position of entry into the nasal cavity, the lacrimal bone is genuinely paper thin and easily broken through. Higher up and more anteriorly, the bone is much thicker and there is more risk of opening an ethmoidal cell. Because of this thickness of the bone in the classical operation, there is a considerable distance between the medial wall of the sac and the mucosa of the nose, creating difficulty in suturing the anterior and posterior flaps together.

The simplified operation described above avoids this step altogether, the nasal and sac mucosz being crimped together by the Kerrison punch.

There is a striking lack of trouble with blood, notably in those cases which usually cause the greatest trouble with bleeding- recurrent acute dacrocystitis. The skin and sac are incised at a stroke. From this point, the entire operation can be performed by touch. When one pushes the Hegar’s dilators through, they actually stop the blood to a large extent and the sphenoidal punch can be used by feeling the bony margins if visability is inadequate.

These differences make the operakion much faster. Half an hour is ample for even a slow and infrequent operator.

A success rate of goo/, is commonly claimed for dacrocystorhinostomy operations by their sponsors. Welham and Henderson (1973) record a 9996 success rate with a t least three months follow-up in a series of 100 cases. Iliff (1971) had 9Ooi successes in a series of 87 cases done by his simplified method.

Tn both the quoted series the criterion of success was relief of symptoms. Iliff high- lights the point that in his series, postoperative irrigations and probings of the tract have not been done to satisfy the surgeon’s curiosity but only if the operative procedure has

apparently failed. His primary success rate was 77 O,,, i.e. 69 out of 87 patients. Secondary procedures had to be performed on another’ ten patients. All his cases were performed personally.

In our series, two surgeons, D. Hart and myself did the greatest number of operations (13 and 15 respectively). Of those which could be adequately reviewed, my final success rate was nine out of ten. The only failure was a female who had no symptoms for over three months. She then had an accident where her spectacles dug into the wound site, causing bruising and recurrence of watering. After another two months there was a slight recurrence of mucopus. As she was now 79-years-old and her symptoms much less than pre-operatively, she decided against further operation.

D. Hart had two primary failures out of thirteen cases, neither of them having secondary procedures.

Eleven surgeons including registrars in training performed the other 34 opemtions, 25 being adequately reviewed with five primary failures.

A surgeon with extensive experience of an operation would normally expect to have ib higher success rate with m y operation, so :l primary success rate of SOo,, in these cases shonld be judged in that light.

Unfortunately, the operation records are inadequate to give a definite opinion as to the Causes of failure. One recorded that the nasal hole was dilated up to a No. 6 Hegar’s dilator and no further enlargement was made. It is obvious that the cause of failure in this case was a totally inadequate hole. I suspect that some of the others failed because of poor selection (vide infru).

In the two cases of technical failure (blocked common canaliculi but freedom from symptoms) the patients were in no doubt as to the success of the operation. They were two of the most grateful patients. They had both suffered the misery and pain of recurrent acute dacrocystitis where surgery was delayed because of fear of inability to control blood loss in the excessively vascular conditions. They were in fact ideal cases for this simplified procedure, the operation being little more than the establishment of dependent drainage of an abscess by the formation of an internal fistula into the nose. It is highly probable that the cause of their trouble was the combined blockage of the nasolacrimal duct and the common canaliculus preventing

SIMPLIFIED DACROCYSTORHINOSTOMY 151

drainage of infected material out of the sac and producing recurrent acute abscess formation. Any attempt to unblock the canaliculi and the creation of classical mucosal flaps would have been difficult in the extreme, in view of the gross hyperamia and friability of the tissues. These were not cases of poor selection for surgery, and if i t were not for our strict criteria, would be deemed successful.

In the six other failures, symptoms of recurrence were not present for at least three months in three of the six cases. I n one of these, the symptoms recurred almost exactly six months after primary surgery. This suggests that’ a follow-up of three months as used in some recorded series is insufficient.

Any case with a mucocele does well with the simplified procedure but scarred atrophic

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sacs are too small to open from the anterior wall. They are better managed by the more painstaking procedures such as that described by \Verb (1971). The same applies to cases of canalicular blockage. Careful pre- operative diagnosis and patient selection are essential for the successful management of any ease of epiphora.

REFEREN~ES ILIFF, C. E. (1971), ‘‘ A Simplified Darrocystorhm-

ostomy ’ I , Arch. Ophthal., 86 : ,586. KINOSIAN, H. J. (1963), “ A Now Technique for

Dacrocystorhinostomy ”, Arch. Ophthal., 70 : 33. WELHAM, R. A. N., and HENDERSON, P. H. (1973),

“ Results of Dac.rocyYtorhitioytomy ”, Tram. Ophthnl. SOC. U.K. , 93 : 601.

WERB, A. (19711, First Internatioiznl Symposium on the LacrimrtZ System, C. V. Mosby Co , St. Louis, 137.

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